Health Assessment Final

orthostatic hypotension

A drop in systolic pressure greater than 20mmHg or 10mmHg in the diastolic after a person goes from a sitting or lying down position to standing up

A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?

A physical obstruction to the transmission of soundwaves

The nurse is performing a neurological assessment on a client and notes a positive Romberg's test. the nurse makes this determination based on which observation?

A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed.

The nurse performing a neurological examination is assessing eye movement to evaluate cranial nerves iii, iv, vi. Using a flashlight, the nurse would perform which action to obtain the assessment data?

Ask the client to follow the flashlight through the 6 cardinal positions of gaze.

The nurse would perform which action to assess for a pulse deficit?

Auscultate the apical heartbeat while palpating the radial artery

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data?

Client reports difficulty sleeping at night

Non-modifiable risk factors

Culture, genetics, race/ethnicity and age

fine crackles

Discontinuous, high-pitched short crackling, popping sounds during inspiration that are not cleared by coughing. This tells us there are restrictive disease processes

Bronchial

Duration: Inspiration < Expiration Normal Location: Trachea and Larynx

bronchovesicular breath sounds

Duration: Inspiration = Expiration Normal Location: Over major bronchi where fewer alveoli are located

vesicular breath sounds

Duration: Inspiration > Expiration Normal Location: Over peripheral lung fields where air flows through smaller bronchioles and alveoli

stridor

High-pitched, inspiratory sounds-AUDIBLE-Medical 911. This tells us there is an upper airway obstruction

testicular self exam

Hold the testicle with both hands, one at a time, and use your thumb and fingers to roll the testicle between them. Feel for lumps, changes in size, or irregularities

coarse crackles

Loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration-may be cleared with coughing but reappear. This tells us there is fluid in the lungs.

Wheezes

Low or high-pitched musical squeaking sounds; may be heard on inspiration or expiration. This tells us there is a narrowing of the airway.

The nurse is preparing to measure the apical pulse on an assigned client. the nurse places the diaphragm of the stethoscope over which cardiac site?

Mitral area

Mormon

alcoholic beverages ,caffeinated beverages; food and beverages on first Sunday of each month

Islam

all pork and pork products; meat not slaughtered; alcoholic beverages and alcoholic products, coffee and tea; food and beverages before sunset during Ramadan

orhtodox judaism

all pork and pork products; meat not slaughtered; all shell fish; dairy products and meat at the same meal; leavened bread and cake during pass overfood and beverages on yom kipper

Seven Day Adventists

all pork and pork products; shell fish meat, dairy products, and eggs; alcoholic beverages, cofee and tea; highly seasoned foods

breast self-examination

an essential self-care procedure for the early detection of breast cancer. sit up and check the armpit.

white or clear sputum

colds, bronchitis, viral infections

s4

stiff/noncompliant ventricles

Left Upper Quadrant (LUQ)

stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal, splenic flexure of colon, part of transverse and descending colon

pleaural friction rub

superficial sound that is coarse and low pitched; grating quality; sounds louder if you push stethoscope against chest wall-STOPS WHEN PATIENT HOLDS THEIR BREATH. This tells us the pleurae is inflamed.

Patient education for prevention of STDs

· Condom use · Vaccines · Females cleanse from front to back

High pressure on the left side

pulmonary congestion

Pink frothy sputum

pulmonary edema

a client is diagnosed with external otitis. which finding would the nurse expect to note on assessment of the client?

redness and swelling in the ear canal

Left Lower Quadrant (LLQ)

Part of descending colonSigmoid colonLeft ovary and tubeLeft ureterLeft spermatic cord

A client is admitted to the hospital with difficulty breathing. which is the BEST approach for the nurse to use in obtaining the clients health history?

Plan short sessions with the client to obtain data

The nurse is performing a respiratory assessment and is auscultating the clients breath sounds. On auscultation, the nurse hears a grating and creaking type of sound. The nurse interprets this to mean that client has which type of sounds?

Pleural friction rub

The nurse is preparing to perform an otoscopic examination on an adult client. Which action should the nurse take to perform this examination?

Pull the pinna up and back before inserting the speculum

When assessing a clients liver during an assessment, the nurse should palpate which abdominal quadrant?

Right upper quadrant

Blood flow through the heart

SVC --> Rt atria --> Tricuspid --> Rt ventricle --> Pulmonic valve --> Lungs --> Lt atria --> Mitral valve --> Lt ventricle --> aortic valve --> aorta --> Body

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment

Sacculating lung sounds obtaining the clients temperature obtaining information about the clients respirations asking the client about a family history of any illness or disease

The nurse is performing a physical examination on an assigned client. which item should the nurse select to test the function of cranial nerve II?

Snellen chart

The nurse is preparing to check the breath sounds of a client. when ascultating for bronchiovesicular breath sounds, the nurse should place the stethoscope over which area?

The major bronchi

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

The right eye is tested, followed by the left eye, and then both eyes are tested.

Assesment of lymphs

Use fingertips in a gentle circular motion to feel the lymph nodes. Start in front of ear and go in a Z motion down to the collar bones.

After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?

Waves of loud gurgles auscultated in all 4 quadrants

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?

Wheezes

While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. the nurse documents the finding and describes the sound as which?

a blowing or swishing noise

Yellow or green sputum

bacterial infection

Hinduism

beef, pork and some fowl; alcohol; garlic and onions; red colored food

Right Lower Quadrant (RLQ)

cecum, appendix, right ovary and tube, right ureter, right spermatic cord

rust colored sputum

pneumococcal pneumonia

High pressure on the right side

distended neck veins and peripheral edema

S3

fluid overload

Stage 3 pressure ulcer

full thickness loss, beginning of a crater, may see subcutaneous fat, may see granular tissue where it's trying to heal, edges are somewhat rolled, no tunneling, not able to see bone or tendons

Unstageable ulcer

if there is a scab above the wound because you cannot see underneath, but cannot remove the scab

The nurse is performing an abdominal assessment and inspects the skin on the client's abdomen. Which assessment teqniuqe should the nurse perform next?

listen to bowel sounds in all 4 quadrants

Right Upper Quadrant (RUQ)

liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon

stage 4 pressure ulcer

loss of full thickness, see muscle bone and tendon, stringy yellowish matter attached to the wound, tunneling

Catholicism

meat by some denominations on ash Wednesday

conductive hearing loss

mechanical dysfunction of the external or middle ear

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which are helpful in assessing for pallor or cyanosis?

nail beds mucus membrane

Stage 1 pressure ulcer

non blanching, intact skin, but red (light skin person easy to see on a dark skin person it will look darker) if caught at this point easily reversible

Modifiable changes for cardiac

nutrition, smoking, alcohol, drugs, exercise

Stage 2 pressure ulcer

partial thickness skin loss, loss epidermis and can see dermis, superficial, shallow, not intact, weeping, sticky, cannot see any fat (comparable to removing a scab)

Sensorineural (Perceptive Loss)

pathology of the inner ear, cranial nerve VIII or auditory areas of the cerebral cortex